Facility Evaluation Report

Licensing Program Analysts (LPAs) Carmen Lopez and Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with licensee Victoria Legaspi.

LPAs arrived at the facility at 9 am. According to the facility’s administrator, the facility has a maximum capacity for six (6) clients, 60 and above, none of which can be non-ambulatory. The facility currently has five (5) residents in care, all of whom are ambulatory. At 9:00 am, LPAs entered the living room, where a bottle of medication, Chloridine HLC for Victoria Legaspi was observed in one of the tables. At 9:05, resident files were reviewed by LPA. At 9:44 am, LPA’s requested staff files, but licensee was busy preparing residents’ meals, in the meantime, LPA took a walk around living room where he found square diapers on the floor, PPE, etc. There is some clutter with boxes in the living room, two vacuum cleaners and fire alarms in boxes. There was a fire extinguisher next to the kitchen that was checked recently.

At 10:05 am, LPA interviewed R3 and at 10:10 am R2. At 10:23 am while walking outside, LPA observed furniture on the outside as well as two (2) mattresses and two (2) commodes. At 10:54 am LPA reviewed facility staff files. At 11:34 am, LPA was on R1 and R4’s room. At 11:35 am, LPA was on the restroom where water temperature reached 113.5 F. At 11:40 am LPA was with Licensee at the back yard, where there was a locked shed, to which licensee did not have a key, and a 2-3 inches hole was observed close by.